Boosted by virtual reality and AI, telesurgery is on the rise


Dr. Sam Browd is a Seattle neurosurgeon who is taking telemedicine and virtual reality technology to a different, unexpected place – the operating room.

Browd is professor of neurological surgery at the University of Washington, an attending neurosurgeon at Seattle Children's Hospital, and cofounder and chief medical officer at health IT vendor Proprio. He has spent the last few years working with engineers and other surgeons to bring the operating room out of the analog world and into the digital.

What they've created is a new technology that provides surgeons a 360-view of surgery by combining virtual reality and artificial intelligence, enabling surgeons to integrate information in new ways. Out of this, too, comes work on telesurgery – the ability to do live surgery in different locations or mentorship and proctorship.

Browd believes this will democratize surgery across the world, including training medical students from thousands of miles away.

Healthcare IT News tapped Browd's expertise in this interview to discuss these technological breakthroughs and how they will help clinicians and patients alike.

Q. Where is the healthcare industry today with regard to telesurgery? Also, please describe your work in creating the ability to do live surgery, mentorship and proctorship.

A. While the healthcare industry at large has gone through many key transitions and iterations, telemedicine is still in its infancy, albeit in a hyper-accelerated mode due to the necessities of providing care during the pandemic. Our thesis from years back was that technology is now positioned to fundamentally take what has been a largely analog space and make it fully digital in terms of the tools used to assist the surgeon and expand their abilities.

Our goal is to use technology to elevate the performance and competency of every surgeon, and capture, analyze and share nuanced knowledge and technical aspects of surgery for training, simulation and eventually clinical decision support that is immediate, relevant and contextual to the case. To make the leap from today to the "Super Surgeons" of tomorrow – that requires the increased use and adoption of technology.

As we look around the world, there are a number of small companies that have started to look at telesurgery. Current technological approaches focus on extending the consumer video conferencing paradigm to use in the operating room. These methods of 2-D display will enable a first pass at telementoring and teleproctorship, but these are fundamentally limited because they solely leverage common RGB cameras placed over or near the operative field.

These are validating approaches relative to our thesis and are a step in the right direction, but it's only the beginning. I have done this in practice recently, remote proctoring a colleague in Australia through a highly technical procedure for the first time. Through this integration, we were able to live-stream the video from the operative microscope, and we communicated live throughout the six-hour operation while I was in my Seattle office.

The challenge is that currently these types of technologies lack the richness, depth and overall context that is obtained by seeing the depth of field, and the immersive experience is lacking. That said, my experience – and the companies emerging in this space – indicate there's a clear interest and need to do virtual mentorship and proctorship.

At Proprio, we believe telesurgery is the ability to take detailed, in-depth data in the operative room and share it in real time, anywhere, and with imperceptible latency, so assisting surgeons can have the experience of depth perception and immersion as if they were in the operative room next to the lead surgeon.

We think this type of experience will provide a myriad of opportunities for education and outreach – and, importantly, facilitate the essential democratization of surgical training and knowledge-sharing to build, grow and foster the next generation of surgeons around the world – importantly positively impacting areas that are underserved and lack access to high-quality surgical care.

Longer term, being able to operate remotely and provide mentor-proctorship, regardless of location, time zone or surgical capabilities, is going to drastically amplify the ability for specialists to more broadly share their skills and provide surgical guidance creating the next generation "Super Surgeons."

Beyond just the betterment of human performance, it is only a matter of time before companies such as Proprio will facilitate the integration and ability of surgical robotics. The success of robotics in surgery is integrally tied to knowing the location, changes and complexity of the anatomy which is operated upon.

Our overarching vision is to take the performance of surgery into the digital age, improving human performance and ultimately facilitating the transfer of knowledge into robotics for the betterment of human care. This unified approach will bring in a whole new generation of immersive, intelligent surgical capabilities for enhancing surgical skills, outcomes, and workflows.

Q. You've said telesurgery democratizes surgery across the world, and training medical students from thousands of miles away. Please elaborate.

A. Right now in the world of surgical training, luck has a factor in who you become as a surgeon. Beyond just innate physical skills, which country you reside in, who you learn from, and what institution you are associated with can drastically influence opportunities for learning, training and gaining experience with the most modern surgical technologies.

It is unfortunate that location can fundamentally drive how good of a surgeon you will become – and that's absolutely unacceptable and fails millions of people who should be demanding high-quality surgery every year around the world.

Training opportunities are limited by the number of mentors and the ability to scale knowledge. To scale that knowledge requires a different way of thinking. The traditional proctorship/apprenticeship only allows a linear scaling of knowledge. To be able to teach more surgeons and scale that knowledge around the world requires a different approach.

Telesurgery/mentorship/proctorship allows a single expert surgeon to teach multiple people either individually or as a group at any location around the world. The ability to scale this knowledge transfer means that the best surgeons in the world can get away from this linear apprenticeship model and share their knowledge with hundreds as many trainees.

This shift could be an industry-definer and game-changer. A further step beyond this approach would be to archive cases, looking at every procedure, every variation and every complication and distill those elements into a structured teaching regimen for surgeons that can be shared, access on-demand and incorporated learnings that today can only be obtained through direct, one-to-one, in-person surgical training.

What makes a surgeon exceptional is not just skill but experience, number of repetitions, variety of surgery pathology, and the complications they have witnessed, experienced and/or gotten their patient in or out of. Beyond innate skill, experience, education and repetition informs how good a surgeon is. It is the classic nature-versus-nurture problem.

Innate ability can only be amplified by experience, teaching, and the ability to safely make mistakes and transform movement, thought and behavior.

Today we train one-to-one, even while in surgery, so you have to either be present for that particular case or relayed to you by a surgeon that's teaching it. This is an unsustainable model and results in a massive bottleneck of skill distillation and empowerment for the next generation, which is already anticipated to suffer from significant, global surgeon shortages despite ongoing population growth.

Other industries have long ago utilized simulation to achieve repetition and ultimately competency. Learning and adopting lessons from fields like aviation are just coming to surgery.

What we'd like to do is to not only have these expert surgeons teach as many people around the world as possible, but also capture and archive their pearls of knowledge that allow them to reach a level of exceptionalism in the operating room. We must strive to create the super surgeons of tomorrow through technology innovation – and bring the digital world, and all that enables, to the operating theater.

Q. What role does virtual reality technology play in telesurgery?

A. Surgery is a tactile, immersive event. It utilizes all of your senses – vision, touch, all of your proprioceptive skills – to see, feel and navigate a case. Virtual reality allows an observer anywhere in the world to experience operations as if they were physically present. Starting with the visual experience of the surgeon, VR creates an opportunity to participate in a surgery with the full breadth and experience one would have if they were physically present.

For example, the ability to look at the surgical field remotely with stereoscopic vision, deep perception and the freedom to move independently around the visual scene of the surgical field is mind-blowing, but achievable. Virtual reality creates an opportunity for more realistic depth perception that is completely different from the current experience of looking at 2-D images or rendered from a microscope.

Depending on the view that's taken, you can learn what's happening across the entire operating room – whether that's the workflow, what the scrub tech or nurse is doing, etc. Whatever is happening in and around the operation, there's a breadth of nuanced and particular in-person knowledge that can come from VR and be translated to broader audiences via the operating surgeon. Workflow, team dynamics, the integration of additive technologies, aside from the visual of the surgery itself, are instructive and part of the overall learning objectives of trainees.

It's much more of an engaging experience to feel like you are present, versus feeling like you are watching a movie. You are transposed to be an active observer versus passive observer. VR places you in the situation and allows you to discover the intricacies and inherent reactions specialists spend years trying to convey – all in that one immersive experience.

I cannot stress enough the difference in recollection and understanding between experiential, active learning versus passive learning. For a resident to experience a surgery and make their own observations in real time, versus memorizing case studies from a flat textbook, the retention abilities are night and day. Contextual learning moments lead to better retention of facts, details and patterns of learning, which ultimately must be retained by the learner to achieve proficiency and competency, but ideally mastery.

Virtual reality creates the ability to see the operating room in a 3-D environment where you can move, manipulate and see it rendered as a volume rather than looking at a static image. It's more enjoyable. It changes the dynamics of the engagement and, ultimately, the effectiveness of the educational experience.

Q. What role does artificial intelligence technology play in telesurgery?

A. Just as immersive technology is drastically impacting industries, artificial intelligence is going to shift the world of medicine in a couple areas, particularly around the concept of data collection, processing and analysis.

There's data and image capture. The technology that allows us to capture images requires securing extremely large data sets in 3-D with low/no latency. There's a lot of work going on in the background with AI on how these extremely large data sets can be manipulated and condensed so that latency happens at a rate that does not create a lag.

You can imagine assisting remotely during a critical portion of the case, you don't want to be sending comments or suggestions that arrive beyond the moment the information is needed to engage or change the course of the operation.

Immersive telesurgery will require AI solutions to improve the speed and efficiency of data transfer, image processing and reconstruction. Additionally, the ideal situation is an untethered headset, so the ability to connect via 5G or other enabling technologies will require thoughtful data techniques that will be driven by AI.

Then there's data and educational advancement. AI allows us to acquire and process significantly more data, this can also translate to increased opportunities for learning and evaluation post-operatively. By combining machine learning and computer vision in the OR, surgeons can evaluate performance and assess opportunities for improvement through more intuitively designed data capture, visualization and, importantly, analysis.

As we acquire data and archive it, we open the ability to not only play back the surgery in an immersive way, it also gives us an opportunity to aggregate, learn and extract what we think recurring features relates to improved performance and workflow. As the operating room becomes digital, this immense aggregated data set will lead to clinical decision making tools that will be brought to the surgeon during a case in a timely, relevant and contextual way to enable the surgeon to see and make decisions based on the world's surgical knowledge and not just their own.

Imagine information that is generated and presented as an operation unfolds to bring suggestions, warnings or other information to the surgeon as the case progresses with contextual relevance. These digital tools will most certainly improve both the safety and efficiency of surgery in the future.

And then there's data and surgical performance. AI creates the opportunity to take robust surgical data collected digitally in the operating room, process and compare moments in that unique case against data obtained over hundreds or thousands of cases to inform the surgeon of information relevant to the anatomy, process and/or outcome of the surgery.

Data sets will inform decision-making during the operation. The more data we have, the more we can learn and share. The goal is surgeons who have the world's best expert surgeon virtually at their side in every case and the experience of thousands of cases, infinite anatomical variation and the outcome metrics to rank-order decision-making surgical support presented in real time to effect the most optimal outcome.

Healthcare IT News is a HIMSS Media publication.